MANAGEMENT OF BURNS

CPT Allen Proulx, MPAS, PA-CCPT Allen Proulx, MPAS, PA-C

OBJECTIVES

Describe the differences between partial Describe the differences between partial and full-thickness burns.and full-thickness burns.

Describe how to estimate the size of a Describe how to estimate the size of a burn.burn.

Describe initial care of burns.Describe initial care of burns.Describe follow-up care of partial Describe follow-up care of partial

thickness burns.thickness burns.

References for photos

Advanced Burn Life Support Course,Advanced Burn Life Support Course,American Burn Association, 1994American Burn Association, 1994

Textbook of Military MedicineTextbook of Military Medicine, Part I, Vol 5, Part I, Vol 5 Conventional Warfare, OTSG, 1991Conventional Warfare, OTSG, 1991 Textbook of SurgeryTextbook of Surgery, Sabiston, editor, Sabiston, editor W. B. Saunders, 1986W. B. Saunders, 1986 SESAP VI, SESAP VI, American College of Surgeons, 1988American College of Surgeons, 1988 Burn care product infoBurn care product info

Depth of burn

Partial thickness Partial thickness burn =burn =

involves epidermisinvolves epidermis

Deep partial Deep partial thickness =thickness =

involves dermisinvolves dermis

Full thickness =Full thickness =

involves all of skininvolves all of skin

Partial thickness burns

Sunburn is a very superficial burn.Sunburn is a very superficial burn. Expect blistering and peeling in a few days.Expect blistering and peeling in a few days. Maintain hydration orally.Maintain hydration orally. Heals in 3-6 days- generally no scaring Heals in 3-6 days- generally no scaring Topical creams provide relief. Topical creams provide relief. No need for antibioticsNo need for antibiotics

Deeper partial thickness

Blisters are typical of partial thickness burns.Blisters are typical of partial thickness burns. Don’t be in a hurry to break the blisters.Don’t be in a hurry to break the blisters. Heals in 14-21 daysHeals in 14-21 days Blisters provide biologic dressing and comfort.Blisters provide biologic dressing and comfort. Once blisters break, red raw surface will be very painful.Once blisters break, red raw surface will be very painful.

Full thickness burn

Yellow, “leathery” appearance; or charredYellow, “leathery” appearance; or charred Often have no sensation (nerve endings destroyed)Often have no sensation (nerve endings destroyed) Outer edges might be partial thickness.Outer edges might be partial thickness. Initial management same as partial thickness.Initial management same as partial thickness. Later will need skin grafts.Later will need skin grafts.

Mixed partial and full thickness

Central yellow area might be full thickness.Central yellow area might be full thickness. Outer edges are probably partial thickness.Outer edges are probably partial thickness. Initial management is the same.Initial management is the same. Later will need skin grafts for the full thickness areas.Later will need skin grafts for the full thickness areas.

Zones of Burn Wounds

Zone of CoagulationZone of Coagulation devitalized, necrotic, white, no devitalized, necrotic, white, no

circulationcirculation Zone of Stasis ‘circulation sluggish’Zone of Stasis ‘circulation sluggish’

may covert to full thickness, mottled may covert to full thickness, mottled redred

Zone of HyperemiaZone of Hyperemia outer rim, good blood flow, redouter rim, good blood flow, red

Wound Wound excision until excision until fine punctate fine punctate

bleeding bleeding occursoccurs

Estimate the size of the burn

The patient’s own palm is about 1% The patient’s own palm is about 1% of his body surface area.of his body surface area.

““Rule of Nines”Rule of Nines”

Rule of 9s

ABA

American Burn Assoc says send these to a burn center

Partial thickness burns >10% BSA Partial thickness burns >10% BSA Burns involving the face, hands, feet, genitalia, Burns involving the face, hands, feet, genitalia,

perineum, or major jointsperineum, or major joints full thickness/3 degree burn full thickness/3 degree burn Electrical, Chemical, and Inhalation burnsElectrical, Chemical, and Inhalation burns

In combat, all but the most superficial burn In combat, all but the most superficial burn should be evacuatedshould be evacuated

Burn care products

< 20% TBSA 2< 20% TBSA 2ndnd degree – Silvadene (SVC) Cream degree – Silvadene (SVC) Cream BIDBID

Any > 20% TBSA-SVC and Sulfamylon (SMC) alt Any > 20% TBSA-SVC and Sulfamylon (SMC) alt BIDBID

33rdrd degree burn – SVC and SMC alt BID degree burn – SVC and SMC alt BID *SMC only to the ears * Bacitracin Opth to *SMC only to the ears * Bacitracin Opth to

faceface

Care of small burns

What can YOU do?

Care of small burns

Clean entire limb with Clean entire limb with

soap and water (also under nails).soap and water (also under nails). Apply antibiotic cream Apply antibiotic cream

(no PO or IV antibiotic).(no PO or IV antibiotic). Dress limb in position of function, Dress limb in position of function,

and elevate it.and elevate it. No hurry to remove blistersNo hurry to remove blisters unless infection occurs. unless infection occurs. Give pain meds as needed (PO, IM, or IV) Give pain meds as needed (PO, IM, or IV) Rinse daily in clean water; in shower is very practical.Rinse daily in clean water; in shower is very practical. GentlyGently wipe off with clean gauze. wipe off with clean gauze.

Blisters

In the pre-hospital setting, there is no In the pre-hospital setting, there is no hurry to remove blisters. hurry to remove blisters.

Leaving the blister intact initially is less Leaving the blister intact initially is less painful and requires fewer dressing painful and requires fewer dressing changes. changes.

The blister will either break on its own, The blister will either break on its own, or the fluid will be resorbed. or the fluid will be resorbed.

Blisters break on their own

Upper arm burn day 1 day 2Upper arm burn day 1 day 2

Burn “looks worse” the next day because of blisters breaking and oozing

Upper arm burn

Blisters show probable partial thickness burn.Blisters show probable partial thickness burn. Area without blister might be deeper partial Area without blister might be deeper partial

thickness.thickness.

121

Debride blister using simple instruments

Medic debriding blister

After debridement

Before and after debridement

Removing the blister leaves a weeping, very Removing the blister leaves a weeping, very tender wound, that requires much care.tender wound, that requires much care.

Silver sulfadiazene

Arm burn 4 days

Arm burn 7 days – note the exudate

Foot burn debridement

Before debriding and applying cream, clean entire foot(including toes and nails).

Silver- impregnated dressings (Silverlon)

Apply wet silver dressing Apply wet silver dressing

directly on the burn.directly on the burn. Creams or dressings Creams or dressings

under the silver dressing under the silver dressing

impede the antimicrobial action.impede the antimicrobial action. Keep it moist!Keep it moist! Remove it, rinse it out, replace it on the Remove it, rinse it out, replace it on the

burn.burn.

Steps in using silver-impregnated dressings

Clean the burn and surrounding area. Clean the burn and surrounding area. Soak silver-impregnated dressing and gauze in Soak silver-impregnated dressing and gauze in STERILE WATER or BOTTLED DRINKING STERILE WATER or BOTTLED DRINKING

WATER WATER Apply silver-impregnated dressing Apply silver-impregnated dressing

(over-lapping edges are best). (over-lapping edges are best). Wrap with the moist gauze. Wrap with the moist gauze. Secure with mesh, gauze, or tape.Secure with mesh, gauze, or tape. Keep it moist with WATER, every 12h or so Keep it moist with WATER, every 12h or so

More frequent in hot arid environmentsMore frequent in hot arid environments

picsSoak silver dressings and gauze in WATER (not saline).

Apply thesilver dressing.

Wrap with moist gauze.Secure with mesh, gauze, or tape.

First few days Moisten dressing with WATER every 12h or so.Moisten dressing with WATER every 12h or so. Remove outer gauze and silver dressing every Remove outer gauze and silver dressing every

day.day.Inspect the burn. Inspect the burn. Rinse exudate off burn.Rinse exudate off burn.

Rinse exudate off silver dressing with WATER.Rinse exudate off silver dressing with WATER. Return same silver dressing to the burn.Return same silver dressing to the burn. Apply new outer gauze moistened with WATER.Apply new outer gauze moistened with WATER.

pics Moisten with WATER q12h or so.

Moisten wellto remove it each day.Rinse it out, and put it back on the burn.

After several days

Replace silver dressing Replace silver dressing every 2 - 5 days every 2 - 5 days depending on amount of exudate, depending on amount of exudate,

cellular debriscellular debris First wet the silver dressing before removing First wet the silver dressing before removing

it.it. Don’t pull on it if it’s stuck – moisten it more.Don’t pull on it if it’s stuck – moisten it more. Apply new moist silver dressing and gauze.Apply new moist silver dressing and gauze.

QUESTIONS ABOUT SMALL BURNS?

SUMMARYSUMMARY

Describe the differences between partial and Describe the differences between partial and full-thickness burns.full-thickness burns.

Describe how to estimate the size of a burn.Describe how to estimate the size of a burn. Describe initial care of small burns.Describe initial care of small burns. Describe follow-up and post-burn care.Describe follow-up and post-burn care.

NEXT TOPIC - BURNS OF SPECIAL AREASNEXT TOPIC - BURNS OF SPECIAL AREAS

Burns of special areasof the body

Face Face MouthMouth NeckNeck Hands and feetHands and feet GenitaliaGenitalia

Face Be Be VERYVERY concerned for the airway!! concerned for the airway!! Eyelids, lips and ears often swell Eyelids, lips and ears often swell

alarmingly.alarmingly. In fact, they look even worse the next day.In fact, they look even worse the next day. But they will start to improve daily after But they will start to improve daily after

that.that. Cleanse eyes with warm water or saline. Cleanse eyes with warm water or saline. Apply antibiotic ointment or liquid tears Apply antibiotic ointment or liquid tears

until lids are no longer swollen shut. until lids are no longer swollen shut. Bacitracin cream/ointment will serveBacitracin cream/ointment will serve

Hands and feet

This is rather deep This is rather deep and might require and might require grafting. grafting.

But initial But initial management is basic.management is basic.

Dressings should not impede Dressings should not impede circulation.circulation.

Leave tips of fingers exposed.Leave tips of fingers exposed.

Keep limb elevated.Keep limb elevated.

Hands and feet

Allow use of the hands in dressings by day.Allow use of the hands in dressings by day. Splint in functional position by night.Splint in functional position by night. Keep elevated to reduce swelling.Keep elevated to reduce swelling.

Hands and feet Fingers might develop Fingers might develop

contractures if active contractures if active measures are not taken measures are not taken to prevent them.to prevent them.

Genitalia

Shower daily, rinse off old cream, apply new cream.Shower daily, rinse off old cream, apply new cream. Insert Foley catheter if unable to urinate due to swelling.Insert Foley catheter if unable to urinate due to swelling.

Large Burns

Causes of death in burn patientsAirway Airway

Facial edema, and/or airway edemaFacial edema, and/or airway edema

BreathingBreathingToxic inhalation (CO, +/- CN)Toxic inhalation (CO, +/- CN)Respiratory failure due to smoke Respiratory failure due to smoke

injury or ARDSinjury or ARDS

Edema Formation

Amount of edema can be Amount of edema can be immense (even without immense (even without facial burns)facial burns)

Depression of mental Depression of mental status can worsen problemstatus can worsen problem

Edema peaks at 12 to 24 Edema peaks at 12 to 24 hourshours

Pediatric patients even Pediatric patients even more concerningmore concerning

Causes of death in burn patientsCirculation: “failure of resuscitation”Circulation: “failure of resuscitation”

Cardiovascular collapse, or acute Cardiovascular collapse, or acute MIMI

Acute renal failureAcute renal failureOther end organ failureOther end organ failure

Missed non-thermal injuryMissed non-thermal injury

Patients with larger burnsFirst assessFirst assess

CBA’sCBA’s““Disability” (brief neuro exam)Disability” (brief neuro exam)Expose Expose

LaterLaterExamine rest of patientExamine rest of patientCalculate IV fluidsCalculate IV fluidsTreat burnTreat burn

Airway? ““Flash” burns may refer to Flash” burns may refer to

those that suddenly flare up, those that suddenly flare up, then die down quickly. then die down quickly.

Patients may have burnt facial Patients may have burnt facial hair and carbon on lips.hair and carbon on lips.

Patients with this kind of facial Patients with this kind of facial burn will probably NOT need an burn will probably NOT need an artificial airway.artificial airway.

Give humidified oxygen while Give humidified oxygen while under close observation.under close observation.

Circulation Record Record vital signsvital signs.. Check distal Check distal pulsespulses and and nail bedsnail beds..

Keep him warm!Keep him warm!Loss of skin impairs ability to retain heat and fluids.Loss of skin impairs ability to retain heat and fluids.Being cold will cause vasoconstriction.Being cold will cause vasoconstriction.

Monitor Monitor urine outputurine output (in larger burns, insert Foley catheter for hourly urine (in larger burns, insert Foley catheter for hourly urine output). 30/50cc/hroutput). 30/50cc/hr

Monitor at least Monitor at least HCTHCT and and urine specific gravityurine specific gravity.. When available, monitor electrolytes.When available, monitor electrolytes.

Neuro status The burn itself does not alter the level of consciousness.The burn itself does not alter the level of consciousness. If patient is not alert, think of other causes:If patient is not alert, think of other causes:

hypovolemiahypovolemiacarbon monoxidecarbon monoxidehead injuryhead injury

Don’t allow swollen eyelids to prevent you from examining the pupils.Don’t allow swollen eyelids to prevent you from examining the pupils. Test sensation and motion in burned extremities.Test sensation and motion in burned extremities.

Expose Undress the patient to examine Undress the patient to examine

the whole body.the whole body. But burned patients lose body But burned patients lose body

heat quickly, so keep them heat quickly, so keep them warm.warm.

To keep warm, use whatever To keep warm, use whatever means available:means available:

blanketsblankets

heating lampsheating lamps

bed framebed frame

large box covered with large box covered with blanketsblankets

Head to toe exam

Obtain history and examine rest of body.Obtain history and examine rest of body.Ask about allergies, meds, medical Ask about allergies, meds, medical

conditions.conditions.Look for other injuries.Look for other injuries.

Calculate fluid requirements

wt in kg x % burn x 2 - 4cc / kg / %wt in kg x % burn x 2 - 4cc / kg / %

100 kg patient with 50% TBSA burn:100 kg patient with 50% TBSA burn:

100 x 50 x 2 = 10,000cc = 10 liters RL100 x 50 x 2 = 10,000cc = 10 liters RL

This is calculated for the first 24 hours post-burn.This is calculated for the first 24 hours post-burn.

Give half of this in first 8 hours. Give half of this in first 8 hours.

Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

Calculate fluid requirements

Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initiallyHalf of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

How do we know if this is too much fluid, or too little?How do we know if this is too much fluid, or too little?

Monitor at least: Monitor at least:

urine output - in adults, around 50 cc / hrurine output - in adults, around 50 cc / hr

Decreasing urine output = need for more fluids.Decreasing urine output = need for more fluids.

Burn size in small children

The head accounts for about 18% (instead of 9%).The head accounts for about 18% (instead of 9%). The legs account for about 13% (instead of 18%).The legs account for about 13% (instead of 18%).

Fluid requirements in children

Use same formula for fluids to replace loss from Use same formula for fluids to replace loss from burns.burns.

In children, add this amount to normal maintenance In children, add this amount to normal maintenance rate:rate:

10 kg - about 40 cc / hr maintenance fluids10 kg - about 40 cc / hr maintenance fluids

20 kg - about 60 cc / hr20 kg - about 60 cc / hr

30 kg - about 70 cc / hr30 kg - about 70 cc / hr

Expected urine output for child: 1 cc / kg /hr Expected urine output for child: 1 cc / kg /hr

for infant: 2 cc/ kg / hr for infant: 2 cc/ kg / hr

Fluids requirements in children

20 kg child with 30% burn:20 kg child with 30% burn:20 (kg) x 30(%) x 2 (cc/kg/%) = 1200 cc in 24 hr20 (kg) x 30(%) x 2 (cc/kg/%) = 1200 cc in 24 hrHalf of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initiallyHalf of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initially75 cc / hr for burn loss + normal 60 cc / hr maintenance =75 cc / hr for burn loss + normal 60 cc / hr maintenance =135 cc / hr initially135 cc / hr initially

How do you know if the patient is getting too much fluid,How do you know if the patient is getting too much fluid, or too little? or too little? Check urine output, urine specific gravity, HCTCheck urine output, urine specific gravity, HCT

Be sure the patient’s airway, breathing and Be sure the patient’s airway, breathing and circulation are secure.circulation are secure.

Then treat the burn wound itself.Then treat the burn wound itself. In patients with large burns, do not initially In patients with large burns, do not initially

spend much time carefully calculating fluids. spend much time carefully calculating fluids. Instead, start an IV and start giving fluids Instead, start an IV and start giving fluids

rather rapidly while exam is being performed. rather rapidly while exam is being performed. DO NOT BOLUS! 500cc/hr is a good rule.DO NOT BOLUS! 500cc/hr is a good rule.

Later do the calculations.Later do the calculations.

Special types of burn

Circumferential burnCircumferential burn Burn requiring escharotomyBurn requiring escharotomy Electrical burnElectrical burn Chemical burnChemical burn

Circumferential burn

Limb is burned all the way around.Limb is burned all the way around. Soft tissues under the skin always swell with Soft tissues under the skin always swell with

burnsburns (due to capillary leak of fluids in first day or so).(due to capillary leak of fluids in first day or so). There is a loss of skin expansion due to the loss There is a loss of skin expansion due to the loss

of turgor/elasticity in burned tissue of turgor/elasticity in burned tissue Pressure inside limb gradually increases.Pressure inside limb gradually increases. Eventually, pressure inside limb exceeds arterial Eventually, pressure inside limb exceeds arterial

pressure.pressure. This requires escharotomy to relieve the This requires escharotomy to relieve the

pressure.pressure.

Escharotomy - indications

Circulation to distal limb is in danger due to swelling.Circulation to distal limb is in danger due to swelling.Progressive loss of sensation / motion in hand / foot.Progressive loss of sensation / motion in hand / foot.Progressive loss of pulses in the distal extremity by Progressive loss of pulses in the distal extremity by

palpation or doppler. palpation or doppler. In circumferential chest burn, patient might not be able to In circumferential chest burn, patient might not be able to

expand his chest enough to ventilate, and expand his chest enough to ventilate, and might need escharotomy of the skin of the chest.might need escharotomy of the skin of the chest.

Escharotomy - complications

COMPLICATIONSCOMPLICATIONS Bleeding: might require ligation of superficial veinsBleeding: might require ligation of superficial veins Injury to other structures: arteries, nerves, tendonsInjury to other structures: arteries, nerves, tendonsNOT every circumferential burn requires escharotomy.NOT every circumferential burn requires escharotomy. In fact, most DO NOT need escharotomy.In fact, most DO NOT need escharotomy. Repeatedly assess neuro-vascular status of the limb.Repeatedly assess neuro-vascular status of the limb. Those that lose circulation and sensation need Those that lose circulation and sensation need

escharotomy.escharotomy.

Escharotomy

Eschar = burned skinEschar = burned skin Escharotomy = cut burned skin to Escharotomy = cut burned skin to

relieve underlying pressurerelieve underlying pressure Similar to bivalving a tight cast.Similar to bivalving a tight cast. Cut along inside and outside of Cut along inside and outside of

limb from good skin to good skinlimb from good skin to good skin Knife can be used, or cautery.Knife can be used, or cautery. Use local or no anesthesia. Use local or no anesthesia. (Full-thickness burn should have (Full-thickness burn should have

no sensation, but underlying no sensation, but underlying tissues do!)tissues do!)

Escharotomy of forearm

Incise along medial Incise along medial and/or lateral surfaces.and/or lateral surfaces.

Avoid bony Avoid bony prominences.prominences.

Avoid tendons, nerves, Avoid tendons, nerves, major vessels.major vessels.

Escharotomy Patient had escharotomy ofPatient had escharotomy of

both legs.both legs. Incisions will heal.Incisions will heal. They will not be closed by They will not be closed by

DPC.DPC. These large burns are often These large burns are often

treated by the “open” treated by the “open” technique,technique,

that is, without dressings. that is, without dressings.

Electrical burn Outer skin mightOuter skin might not appear too bad.not appear too bad.

But heat was conducted But heat was conducted along the bone.along the bone.

Causes the most damage.Causes the most damage.

Burns from inside out.Burns from inside out.

Usually requires fasciotomyUsually requires fasciotomy

Fasciotomy

Fascia = thick white covering of muscles.Fascia = thick white covering of muscles. Fasciotomy = fascia is incised (and often overlying skin)Fasciotomy = fascia is incised (and often overlying skin) Skin and fascia split open due to underlying swelling.Skin and fascia split open due to underlying swelling. Blood flow to distal limb is improved.Blood flow to distal limb is improved. Muscle can be inspected for viability.Muscle can be inspected for viability.

Phosphorus

Particles of phosphorus must be Particles of phosphorus must be removed from under the skin.removed from under the skin.

Pick them off with forceps.Pick them off with forceps. Must apply wet dressing to Must apply wet dressing to

prevent re-igniting.prevent re-igniting.

QUESTIONS?SUMMARY

Describe how to estimate the body Describe how to estimate the body surface area of burn.surface area of burn.

Describe how to calculate initial fluid Describe how to calculate initial fluid requirements in a patient with a large requirements in a patient with a large burn.burn.

Describe intial management of a patient Describe intial management of a patient with a large burn.with a large burn.

Discuss indications and complications Discuss indications and complications of escharotomy.of escharotomy.

BURN DOWN & DIRTY

Educate your Task Force!Educate your Task Force! proper technique for burning waste, proper technique for burning waste,

wear of clothingwear of clothingDo not hesitate to evacuate. Do not hesitate to evacuate. Burns other than inhalation generally Burns other than inhalation generally

don’t kill at point of injury- Bleeding and don’t kill at point of injury- Bleeding and breathing injuries do!breathing injuries do!

Oral Abx if managing burn at BAS ? Oral Abx if managing burn at BAS ?